She’s a Foot Soldier in America’s Losing War With Chronic Disease
In places like Mingo County, W.Va., where working-age people are dying at record rates, a nurse learns what it takes to make America healthy.
Sam Runyon, a nurse, treats Cora Perkins at home in Williamson, W.Va. All of her patients have at least one chronic disease.
She’s a Foot Soldier in America’s Losing War With Chronic Disease
In places like Mingo County, W.Va., where working-age people are dying at record rates, a nurse learns what it takes to make America healthy.
Sam Runyon, a nurse, treats Cora Perkins at home in Williamson, W.Va. All of her patients have at least one chronic disease.Credit...
By Eli Saslow
Photographs by Erin Schaff
- Published March 2, 2025 Updated March 3, 2025, 10:26 a.m. ET
Sam Runyon navigated to the house by memory as she reviewed her patient’s file, a “problem list” of medications and chronic diseases that went on for several pages. Sam, a 45-year-old nurse, had already seen Cora Perkins survive two types of cancer. During previous appointments, she had found Cora’s arms turning blue from diabetes, or her ankles swollen from congestive heart failure, or her stomach cramping from hunger with no fresh food left in the house. It had been a week since Sam’s last visit, and she wondered if anyone had come or gone through the front door since.
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She knocked, but nobody answered. She walked across the porch to a hole in the window and called into the house. “Cora, honey? Are you OK?” A light flickered inside. A dog began to bark. Sam pushed open the door and walked into the living room, where she found Cora wrapped under a blanket.
“Sam. Thank God you’re here,” said Cora, 64. She tried to stand, but she lost her balance and sat back down in a recliner.
“It looks like you’re wobbly this morning,” Sam said. “Are you feeling really bad or just normal bad?”
It was the same question she asked her patients dozens of times each week as she made home visits across West Virginia, traveling from one impending emergency to the next in a country where feeling bad had become the new normal. All 31 patients in her caseload for the Williamson Health and Wellness Center were under 65 years old, and yet each had at least one of the chronic diseases that had become endemic in the United States over the last two decades: death rates up 25 percent nationally from diabetes, 40 percent from liver disease, 60 percent from kidney disease, 80 percent from hypertension and more than 95 percent from obesity, according to data from the Centers for Disease Control and Prevention.
Sam was offered a job at a hospital, but she prefers the intimacy of home visits.
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Most of Sam’s patients have to manage several chronic diseases.
Americans now spend more years living with chronic disease than people in 183 other countries in the World Health Organization — a reality that Robert F. Kennedy Jr. framed as a “national crisis” in his first weeks as health secretary. “We will reverse the chronic disease epidemic and make America healthy again,” he was promising members of Congress that same morning, while Sam confronted the challenges of that work in Mingo County, where the average life expectancy had been dropping steadily for a decade to 67 years old.
“Are we calling that your breakfast?” Sam asked, pointing to Cora’s side table, where two bottles of sugar-free Dr Pepper sat next to a bag of pepperoni-flavored Combos.
“It’s the end of the month,” Cora said. “It’s whatever’s left. I got the pops on sale at Dollar Tree.”
“You know Dollar Tree isn’t a good place to buy real groceries,” Sam said.
“How am I supposed to get to the grocery store if I don’t have a car?” Cora said.
Sam had been visiting Cora every week for almost two years, helping her to lose 40 pounds, stabilize her blood sugar levels and lower her cholesterol back into the normal range, but each problem they solved revealed another. Cora and her live-in boyfriend regularly had less than $100 in their joint bank account, so she needed help applying for government assistance. She finally qualified for food stamps, but she had no way to go shopping. She occasionally managed to buy meat and vegetables, but her oven was usually broken, so instead she relied on the cheap, ultraprocessed foods that make up 73 percent of the U.S. food supply. Those foods made her sick. Her illnesses made her anxious and depressed. Anxiety raised her blood pressure and complicated her ability to manage diabetes.
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Sam’s graduation portrait hanging in her dad’s home, where plastic in a doorway helps hold in the heat.
“I don’t mean to nag you,” Sam said. “I know it feels impossible. I can see how hard you’re trying.”
She took out a blood pressure cuff and started her examination while two dogs crawled over her lap and nipped at her neck. She had been offered an extra $8 an hour to work as a nurse at a nearby hospital, with a sterile office and a support staff, but she preferred the messy intimacy of home visits, where she could spend an hour with her patients and see the systemic decay behind their conditions. She’d grown up nearby in another drafty rental home, and she knew how to spot the empty jar of cooking oil in Cora’s kitchen, the collection notice on the refrigerator for an electric bill of $766, and the pill box on the counter with several outdated prescription medications.
Many of Sam’s patients stabilized and even got well. They were more likely to take their medications and less likely to visit the emergency room while under her care. More than half lowered their average blood sugar levels or improved their kidney function. But in other cases, no amount of intervention was enough to stop the progression of chronic disease, and Sam ended up listed among the survivors in her patients’ obituaries.
“We’ve still got work to do,” she told Cora. Her blood pressure was high. Her resting pulse rate was 93. Her legs were swollen from eating too much salt. Sam went back to her car and brought in a box from a nearby pantry that had some canned goods, noodles and a bag of potatoes.
“I’m sorry it’s not more nutritious,” Sam said, as she packed her nursing bag and gave Cora a hug.
“I’m pretty much used to the junk,” Cora said.
“You and everyone else,” Sam said.
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Sam’s caseload in Williamson, the county seat of Mingo, reflected the broader upward trend of chronic disease in the United States.
She had worn out five cars while visiting patients on the back roads of Mingo County, and over time she had come to recognize every pothole, every scar on the hillsides left from logging, deep mining and mountaintop removal. It was a place where every resource, including the residents, had been exploited for a profit. Sam turned into Williamson, population 3,042, where two local pharmacies had distributed more than 20 million opioid painkillers over the course of a decade, though the drugs didn’t so much numb people’s pain as exacerbate it. Now the downtown was largely vacant except for rehab centers, budget law offices and a methadone clinic. She drove by a liquor store offering three-for-one shooters of vodka and a gas station advertising two-liter bottles of soda for a dollar each. “Every business is either trying to kill you or selling a cure,” she said.
She pulled up to a house on the edge of downtown to check on another diabetic patient, Joe Miller, 48, who was lying shirtless on his bed, immobilized from hip pain as his pit bull chewed his socks. On his night stand was a bowl of Kraft macaroni and cheese, a box of salt and a photograph of him from a few years earlier — thin and smiling in a button-down shirt, his arm wrapped around his wife. Now she was dead of a heart attack in her 40s, and he was struggling with depression and closing in on 300 pounds with dangerously high cholesterol. He told Sam he’d kept having a recurring nightmare in which he found dynamite stuffed inside his chest.
She reached for his wrist to take his pulse and measured his heart rate at 130 beats per minute.
“Geez, Joe,” she said. “Are you sneaking out to ride roller coasters on me?”
He pointed to a portable toilet in the corner of the room. “That’s about as far as I’ve moved from this bed in two weeks,” he said. “It’s so sad I can’t help but laugh.”
“Well, we might as well try to bring some light to the situation,” Sam said. “But I can tell you’re in pain, and I hate that. Let’s set you up to talk with a counselor.”
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Sam taking the temperature of Joe Miller, one of her patients.
She got back into her car and followed the Tug River into the mountains as she opened her second energy drink of the day. “You have to cope with the stress somehow,” she said. “If there are any saints around here, I haven’t found them.” About half of the county’s 22,000 residents were obese, a quarter of them smoked cigarettes and almost 20 percent were diabetic — numbers that had become increasingly typical in rural America, where working-age adults were dying at higher rates than they were 20 years earlier, according to data from the C.D.C. People in the country’s poorest places were now almost twice as likely to develop chronic disease as those who lived in wealthy, urban centers on the coasts, helping to create a political climate of resentment. Mingo County had been solidly Democratic for much of its history, but more than 85 percent of voters supported Donald J. Trump in the 2024 presidential election.
